OPENING OF THE SURGICAL SESSION FOR 1868-9.

Introductory Address

BY

WILLIAM HARGRAVE, Professor of Surgery.

MR. PRESIDENT, VICE-PRESIDENT, MEMBERS OF COUNCIL, AND GENTLEMEN,-In considering the progress of medicine and of the profession, it has experienced two remarkable epochs within a few years; one of which has been subjected to the test of experience, and has more than fully proved its value, though passed by the Government against great ignorance, prejudice, and opposition. I allude to Mr. Warburton's Anatomy Billthe greatest boon ever granted by the Government to our profession, which has not alone humanised the study of anatomy, but has also facilitated the cultivation of it in all its details and departments; so that even the fair sex can now study it, and profit by it. Gentlemen need not laugh at this statement, when I inform them that prior to and during the great French Revolution of 1789, a Parisian surgeon, who taught anatomy and surgery, named Andravi, was assisted by his daughter, Mademoiselle Andravi, who prepared his subjects for his anatomical lectures in the most perfect and neat manner by her dissections. It has done more in effecting a great moral change, by removing from it a great cause of immorality, dissipation, and degradation, never to return. In olden time some national honour would have been conferred on Mr. Warburton for the great benefit he conferred on science and on humanity; but as it is, so long as sickness and disease exist in these countries, and the necessity of anatomical studies, his memory will never perish. All have agreed on the benefits of this measure.

The second epoch is the passing of the Medical Reform Act. The differences of opinion entertained concerning it does not at all surprise me. As to the value and benefits derived from this measure, and of its working, also as to the endeavours of the Medical Council under the Act to be of use to the profession, some consider it to be of no use, others laugh at its recommendations, which they consider powerless, consequently useless, but which are considered and framed with great delicacy and practical good sense, both for the profession and for the licensing bodies; while another party is specially severe, and has more than once publicly stated and condemned in no unmeasured language the endeavours of the Council to carry out in the fullest manner the powers given to them by it, indicating

the good it has effected-if not against the opposition of the Universities and Colleges, certainly in the first instance it was not met in a kindly spirit to carry out the recommendations of the Council. Could this have arisen from any jealousy from the senior institutions to a junior one? Another section of the profession thinks the Bill should be repealed, and a new one sought for, evidently to meet their views, which would be going from bad to worse, and "tis better bear these ills we have than fly to others that we know not of." Lastly, some maintain that the Council consists of nothing but committees -the strangest of all charges against it.

Such individuals and cavillers know nothing of the working of public bodies, the chief business of which is carried out by such arrangements. I need scarcely allude to our Parliamentary councils to prove the great importance of committees ; certainly as to the Medical Council, their committees enjoy no sinecure, when some of them devote almost the entire of the day to these duties of course including the sitting of the

Council.

and wrought into harmony if the profession would but study These different and antagonistic opinions can be reconciled what has been the result of this Act up to the present time, imperfect as it is confessed to be in some of its powers.

Permit me to make a few remarks on the benefits derived even now from it, bearing in mind its title, "An Act to Regulate the Qualifications of Practitioners in Medicine and Sur

gery," while the third clause constitutes the formation of a council styled, "The General Council of Medical Education and Registration in the United Kingdom."

following five subjects bearing specially on the student entering If we examine this Act, it presents to our consideration the on the study of his profession :

1. Preliminary or classical education and examination. 2. Registration of the students.

3. Time and duration or period of his professional study. 4. Professional examinations.

5. The "British Pharmacopoeia."

I shall in the first instance solicit your attention to the Pharmacopoeia, though the last in my list.

Since the passing of the Medical Act in 1858, no less than four Acts have been passed by the Legislature to amend and improve the original one; the one which I wish particularly to direct your attention to is the last, passed in 1864, “ An Act to Incorporate the General Council of Medical Education and Registration, and for other purposes." This Act has made the Council a corporate body, has given it a common seal, and allowed it to purchase land for the corporation; these privileges were never asked for by the Council-nay, not even thought of by it; but what it sought for from the Government was the sole right over the "British Pharmacopoeia," which

was granted, provided the Colleges of Physicians of England, Ireland, and Scotland would resign their rights over their respective Pharmacopoeias. The only condition required with this boon was that the Government should decide on the price of the work. These Acts prove in my judgment that the Government are favourably disposed both to the Council and to the profession.

on. Clauses XX., XXI., XXII., give this power to the Medical Council.

3. Registration of students, which is for the purpose of ascertaining the name, date of preliminary examination, and place of study. None can deny but that the General Council have acted with judgment to ascertain what general education the pupils have had before entering on the study of their profession; strange to say that some of the Universities have set at nought these recommendations. I must give the students of this College the credit that, with very few exceptions, they are not disposed to neglect their registrations.

4. Professional education and curriculum. The effort is being made by the Council to establish, as far as can be effected, or as near as can be, uniformity in the curriculum for the student, order and method in their attendance. This is a more difficult subject to arrange than at first it seems to be, for each body is so wedded to what they consider the best, and which they have pursued for such a number of years, that they are tardy in making any decided changes in their curricula. However, action is now decidedly taken on this important question-a curriculum of ten subjects-Anatomy, General Anatomy, Physiology, Chemistry, Materia Medica, Practical Pharmacy, Medicine, Surgery, Midwifery, and Forensic Medicine-which must be well known by strict examination of the student before he can obtain his qualification to practise his profession. This curriculum could be much improved by adding Botany to it, and which I expect yet to see done. It is now submitted to twelve members of Council as a committee sitting en permanence, which are empowered to seek for the opinions of professors, lecturers, and other medical practitioners in the three kingdoms on it, and to report them to the permanent committee, who are to make the final report to the Council next year for their decision and adoption.

If uniformity in preliminary education and examination, in registration, and in professional education is attained, then will follow that of professional examinations, both theoretical and practical.

Without waiting for additional legislation, a great advance has been made in the examinations for the licence to practise, by separating them into half-yearly, quarterly, or even yearly, which relieves the student of the heavy responsibility of undergoing at the same and one examination the testing of his four years' study and the knowledge derived from it.

In addition to these efforts of the Council to benefit the profession, is that of the visitation of examinations of the various licensing bodies, from which much improvement has followed, by inducing some of them to elevate the standard of their examinations to a higher rank, thereby adding to their own character and reflecting it on their students.

Though admitted by all that the Council have no direct coercive powers to carry out their recommendations, which for the present, to my conviction, is both wise and prudent; yet they possess indirectly great power, by appealing to the Privy Council to support them, to have their recommendations acted

I have thus endeavoured to give a succinct view of the exertions of the General Medical Council to advance the common weal of our profession, and remove from it a reproach too often brought against it, and most prominently before the public. "There is probably no profession in its aggregate or corporate capacity excites so little the interest of the public, as that which professes to cure or alleviate the ills resulting from the physical constitution of man." This reproach is not founded on fact, but an evidence of the utter ignorance of our profession by those who have made it. Let our motto be-" Tu ne cede malis sed contra audentur ito"; and we all in bonâ fide put ourselves in thoroughness to our work for the public, for the profession, and for ourselves; we will then represent a well-proportioned, graceful, and lofty column, its firm, broad, and solid base immovably fixed upon a sound, comprehensive, and practically useful preliminary education, the shaft ornathe capital constitutes the Corinthian order, crowned with the honours of the well-trained mind, which none can deprive it of. You then go forth through the world conquering and to conquer, by your courtesy, independent action, and mind. Let me now pass from the Medical Council and its endeavours for the advancement of the profession, which will do its duty to it at all hazards, to the special objects of this lec ture what suggestions I would make to the students to occupy their four years of study most profitably to themselves. Some years since, when examined as President of the Royal College of Surgeons, by Mr. Grogan's Parliamentary committee, for restoring the grants to the Dublin Hospitals, the first question put to me, was: What is the character of the Dublin Surgical and Medical School? My reply was: It is essentially practical. How proved? By the unrivalled facilities of teaching and learning anatomy; by its superior clinical teaching; and by its hospital courtesy, which allows the pupils of every other hospital to witness, not alone rare operations, but also rare cases in medicine; and all the works issuing from it are also essentially practical; and by the manner in which the private schools, recognised by the Royal College of Surgeons, discharge their important trusts in good teaching.

I sincerely hope and entreat that no student who is now commencing the study of his profession, or resuming his studies, will be content with the meagre idea of merely scraping through his examinations for his Letters Testimonial to drug his fellow-man, and to perform bungling and injurious operations upon them. As you have now entered voluntarily on the occupation of your life, make up your minds to devote yourselves to the study of your profession in such a manner that in after life, when engaged in practice, you will retire from any case, however complicated it may be, with the happy reflection that you have done, not your best, but the very best, for your patient.

The essentials of your profession are-Anatomy, Physiology, Surgery, Hospital attendance, Pathology, and Chemistry, the great science of the day; all the others rest upon these fundamentals for future character and success. To enter on some of the specialities bearing upon the teaching and learning of surgery and medicine, we are now at the commencement of, not a transition stage, but a complete revolution, the first great step being to organise a new system to supersede the one which has been in operation so successfully for so many years, and introduce a better one, a great part of which is utopian. One proposition is to change almost in toto the acquiring the knowledge of anatomy, stating both in print and orally that one year of the study of anatomy is sufficient for a surgeon. This proposal appears to me, when advocated by sane men, as one of the most mischievous ever made; it is worse than a mistake, it is a blunder.

We all consider this an age of progress, of advancement in arts, sciences, and of everything of advantage to the human race,; this is a step backwards, it is only that of an impossi bility. Let the student be ever so diligent, attentive, and thorough in work-recollect, I am not alluding to transcendentals, such as John Hunter, a man who appears once in some thousand years-but the pupil of fair ability, intellect, and diligence. What I consider to be the Alpha and Omega, the very backbone-yes, the "To waλov" of surgery and medicine is anatomy; all the others are accessories to that great foundstion. If such a system as now thought of is ever adopted, the nation, for its own safety, will rise against it as one man, and prevent it being adopted by any licensing body. To quote the words of Lord Denman, "it is a delusion, a mockery, and a

snare.

"The Ethiopian cannot change his skin, nor the leopard his spots, neither can any licensing body make a good practical surgeon for one year's anatomy, let his work for that period be ever so sedulous and energetic: even the time required by our College of three sessions, is sufficiently short to make the anatomist which I designate a scalpellary, and not a lingual anatomist-wide is the difference between the two men-one knows it by honourable and untiring use of his scalpel and forceps, which is never forgotten; the other, principally from books, which afford but an ephemeral and fleeting recollection of it. It may be asked-When is the time to commence to learn anatomy? I advise you, from the first winter session. If not acquired in early life, it is a blank after that period, to which you will never return.

It is not my province to enter into details on this most important department of medical science; but I will be allowed to advise you to learn thoroughly the osseous system; if acquired, more than one-half of surgical anatomy, as to operative proceedings and correct diagnosis, will be always in your possession; medical anatomy is much benefitted by it, equally permanent in your recollection; in addition, this knowledge will induct you into a very interesting scientific subject-fossil remaius-and to zoology.

To perfect the study of anatomy, so anxious are the professors to afford every facility to the class that we have added considerably to the staff of the demonstrators, having now nine of these gentlemen sedulously devoted to that object. Surgery and hospital attendance, to be of permanent benefit to the pupil, should be commenced in the very early part of his studies. The sooner he enters on the legitimate exercise of his faculties, always in his possession and at his command, namely, his five senses, the portals to knowledge, to observe, then will follow comparison, reflection, and judgment, the more advantage will he derive from hospital attendance; and as such a pupil he is always accumulating facts of inestimable value in his future professional career. So impressed am I with the value of hospital attendance, I would if possible return to the practice in my student's days. Being an apprentice, I had the great opportunity of attending hospital for five years; but since the period of four years' professional study seems now to be recognised and acquiesced in by all the licensing bodies, the pupil ought to enter as a perpetual one at the commencement of his first session, and devote a portion of each day to the observation of cases and their treatment.

It is evident to me that all licensing bodies err as to hospital attendance, for the purpose of obtaining a practical knowledge of not only surgery, but also of medicine, requiring but 27 months; in place of that period it should be at least 36 months, and not dove-tailing, as it were, these most important subjects into so short a period as that we have mentioned. Whatever advocates may say and advance that this time is sufficient, do they ever reflect when a young man enters an hospital for the first time, let him be ever so observant, and with a well-trained mind, he must pass some time for obtaining an insight of what is before him, and what he is to acquire; bearing in mind I am not speaking of the exceptional student, but one of fair ability, observation, attention, reflection, and self-culture. Again I impress on all to enter as perpetuals for their four years into hospital duties, always being enabled at the same time to learn the value of practical pharmacy. Pathology, for the great advantage derived from it in the science of therapeutics, and in elucidating disease, will claim much of your attention in conjunction with hospital duties, in the study of surgery and medicine, that is the time to learn it; if neglected and the opportunity is not availed of, in after life almost its cultivation is nil, for in private practice much of the pathological investigations are very unsatisfactory, in most instances being too hurriedly made to be of much value; while if in hospital, suppose a patient succumbs to heart affection, renal disease, to hernia, either operated on or not, having attended to any of these cases during life, sometimes the cause of death will be revealed in the most satisfactory manner, always impressed information will be the result.

Some advocate the founding of a special professorship on this subject, but I adhere to the opinion that the hospital and its mortuary is the proper field for its effective study. To make pathology really valuable it must be studied from cause to effect, which can only be done by following the case from the commencement to to its final termination; if in death, then the result is revealed. Plates are of some service, by practising the eye on what is termed morbid anatomy, but they do not convey what is really indicated by practical pathology. Four great results follow from your hospital at

tendance, namely, practical surgery, practical medicine, practical pharmacy, and practical pathology.

Chemistry, the great science of the day, without any comment from me, will recommend itself to your serious attention and study, not alone from its great importance and value it in every department of your profession, butalso from the adjunct it is in acquiring a knowledge of pharmacy. This College affords every facility for being thoroughly informed on it in all its departments, general, practical, organic, and inorganic chemistry, under the able and accurate teaching of our learned Professor of chemistry, in whose family chemical science is hereditary.

If the student is well informed on these fundamental subjects, the imperishable foundation is laid for the sound knowledge of Materia Medica and Therapeutics, practice of medicine, midwifery, forensic medicine, and the other subjects which are accessory, and will not be found difficult, but on the contrary pleasure will attend their studies. One caution is most necessary when attending midwifery; for that session anatomy must be abandoned, not alone in the dissecting room but everywhere else. This will prevent the introduction of disease to the parturient woman, confirmed and acknowledged by, I believe, all obstetricians.

Latterly, two questions are beginning to be agitated by medical men and reformers, namely, the question of lectures, and the attendance on them-whether they should be compulsory, optional, or mixed-whether some should be compulsory and others optional; also the issuing of certificates, termed by some the certificate system. The idea is now commencing to seize the minds of these individuals that there are too many lectures, and no time for reading, reflection, or self-culture-that the student is over-lectured, in fact overweighted, and these sympathising men are apprehensive that the camel's back will break under the feather weight of the lectorial load. Now, what is the fact in this College since its foundation? Lectures have always been in its curriculum, and I have never heard the pupils complaining of the lectures being too numerous; it is the easiest and most facile thing in this life to excite discontent, and worse, when once so excited it is not so readily recovered from. So that if the apple of discord is thrown by serious or mistaken reformers on this question, the student will ultimately become indifferent even to the attendance of one course of lectures. Is the student overtaxed as to lectures in this College? The curriculum which is the most extended of all the licensing bodies, for a period extending over four years requires three Courses of Lectures on Anatomy and Physiology, three on Demonstrations and Dissections, three on Surgery, two on Chemistry, one on Materia Medica, one on Practice of Medicine, one on Forensic Medicine, one on Midwifery, and one on Botany-in all sixteen lectures are attended. Of these lectures eleven in the winter session, extending over a period of four years, and five in the summer sessions; at the rate of three lectures each winter, and allowing full time for hospital attendance and practical anatomy.

The advantages derived from lectures are not a few; they combine both theoretical and practical information, .e., an appeal to the senses which reading fails to impress in that effective manner, so as to make the book work permanent and no further information required; another benefit derived from them is the confidence engendered between the pupils and lecturer, so that he can speak frankly to them of errors of prognosis-diagnosis-consequently, of practice. He can give an accurate and succinct description of some diseases which the pupil has not seen. How few have seen glanders, hydrophobia-perhaps tetanus, either idiopathic or traumatic-and other rare affections. The lecturer has the advantage of ascertaining if his class is keeping pace, or making progress with his instructions by examination of his previous lectures: and is always a referee. They are good aids in strengthening the memory, and if the pupil will follow the lecturer by reflecting and reading in the evening on what he has heard during the day, he can then compare it with what the book teaches; so he has the advantage of learning from two sources the opinions of two different men, and deriving information from each of them. What utopian substitute can be found for good lectures I am at a loss to discover.

In the same category with lectures is the granting of certificates, or as it is called the certificate system; I have heard one condemn them in the following words, "the tyrannous system of certificates has lowered the profession during the last forty years;" that may be the case elsewhere, but not in this country. Another speaker I have heard, not alone sup

porting their tyranny, but adding they are "a farce-dishonest and immoral." With all this condemnation the same gentleman still sigus the condemned certificate. Admitting for argument's sake that there may be some laxity in granting certificates, but denying in toto that they have lowered the profession these last forty years in Ireland, or that they are a farce, the cause of dishonesty or immorality-as long as the attendance on lectures is required, so long will certificates be demanded. Besides the lectures and the certificates there is a third questio vexata, namely, the attendance on lectures. To ascertain the presence of the class, some advocate a roll-call, which is nothing but loss of time with a large class, and not satisfactory evidence of the attendance of it. It has been tried, and failed. Inscribing the names of the pupils is not more beneficial to attain that end. Others suggest a marker to come into the theatre for that purpose. I doubt if much satisfaction will accrue from it.

To meet this question and to solve it, some suggest compulsory attendance on what they consider practical and demonstrative subjects, as Anatomy, Chemistry, Materia Medica -optional for what they consider the systematic lectures. I cannot see the reason for such a distinction: the former might be left to take care for itself, but the latter might be compulsory-however, there should be no difference, no exception, "no halting between two opinions." But admitting that all should be compulsory, I would raise my voice against such an unnecessary proposal. We might compel the presence of the body, but we cannot command the attention of the mind. I incline still to leave it optional. In this College all lectures are demonstrative, not alone on Anatomy and Chemistry, but on Surgery and Practice of Medicine, by drawings, casts, pathological preparations-so the whole course should be made compulsory. I will merely state in the presence of the President and Council of this College, my experience of the students the juniors are diligent and numerous both in at tendance and attention; the seniors, on a lecture which they think they know, may fall off in attendance, but on subjects they are not well acquainted with they are most regular and numerous in their attendance. Recollect it is not the mere lad that we are legislating for, but youths of a certain age, who are morally bound by their engagements when entering at any school to fulfil them, as honourable and truthful men. To solve this question I would prefer to paraphrase partially the advice of the poet of America :

"By winning words to conquer willing minds,

And make good lectures do the work of duty."

It is but right to state that the examinations are everywhere becoming more and more practical, and less theoretical answering is required. From henceforward our College will require practical evidence from the candidate of his proficiency in operative surgery, both upon the dead subject and upon the living one; in the first, by operation on it; in the second, by the application of bandages, splints, measurements for and the application of trusses of all kinds, their mechanism and value, also the knowledge of instruments. I also look forward to the time when the candidate will be tested in hospital practice by cases submitted to him for examination for their prog; nosis and diagnosis, course of the disease and treatment, and in case of a fatal termination what pathological results might be expected; these are additional reasons for pressing on you a longer hospital attendance than is at present required by the licensing boards, which will give the additional advantages of more extended observation, comparison, reflection, judgment, and experience. I have no doubt that the student now commencing his profession will have to undergo this ordeal before he receives his diploma.

I need scarcely add, that in our examinations, councillors attend them, as in the character of assessors, so that each candidate for the diploma is examined separately, and not in class, which is undoubtedly the best way of ascertaining his professional knowledge. That by class is very superficial, and not testing sufficiently his information; the sooner it is abandoned, and the single and separate examination adopted, the better for the character of that licensing body, also for their pupils.

HYGIENE.

There is another department of science particularly applicable to our profession-that of Hygiene, perhaps soon to experience the name of State Medicine, and which, of all the national educational and licensing bodies, was founded first by his College so far back as 1844, and we have had lectures in

the summer delivered on it. During the past one we have had a most practical course on this subject. This theatre was crammed to the very top by professional and non-professional gentlemen, and especially by ladies. I can affirm that many of the last-named visitors availed themselves of the information and practical suggestions of the Professor, and applied them with much benefit in their families. From what I witnessed of the conduct of the gentle and fair sex, they devoted the most intense and active attention to each lecture, affording a good example for some of our students to follow. On this occasion we had the right man, Dr. Cameron, in the right place, with the enviable distinction of being the gallant Professor of the College justly merited by him. Here is a branch of science which ladies have voluntarily pursued, as compeers with man, not for sentimental excitements, not for reading maudlin and mawkish novels of no earthly value, which break down the tone of the mind, and unfit it for studies of a more valuable, exalted, and reflective character. All honour is due to such ladies for so nobly emancipating themselves from such trammels and slavery. To those gentlemen who intend entering the Army and Navy, I would advise to attend these lectures, not alone for their intrinsic merit, but also as preparing the way and making it straight when they enter Netley, where hygiene is one of the most important subjects attended to in that institution. A friend and former pupil of mine was one of the first appointments made in the Abyssinian Expedition, from the evidence he afforded of his knowledge of hygiene. I have somewhere read that that Expedition owed its marked success to the engineering and to the medical hygienic depart. ments.

Mr. President and Council,-It may be considered irrelevant before this audience that I am taking a leap in the dark, and following a vain shadow, to make any allusion, or introduce in any manner a medico-political question; but, gentlemen, in this very critical age, when all are exhibiting such unprece dented and unusual energy in the political, religious, moral, and intellectual world, I freely adopt the dictum which has come to us from Athens, when she was at the zenith of her glory, that every member of a free state should have his opinion, and declare it, that no man should stand or remain neuter; Pericles was the Athenian who enunciated that noble political maxim. What I am solicitous to direct the attention of the seniors and juniors of those present, and by them throughout the country, is, if possible, to pledge each candidate at the approaching election who aspires to the honour of a seat in Parliament, to support by words, and vote the justice of giving to the Poor-law medical officers of this country a retiring superannuation allowance when broken down in health and not able to continue their labours. Our College has generously and liberally expended large sums of money in advocating this measure of tardy justice to the profession, irrespective of being their alumni or of other Colleges. If the Irish members will act together in the next Parliament as one man, which they should do, this claim will be acceded, but if not carried, it is not lost; we must not despair. Let us bear in mind what our own poet says: "The struggle for justice, once begun, though often baffled, is ever won ;" and under the persevering action of our College it shall be obtained. I may add that I was one of a deputation from the College who waited on Mr. Chatterton, the Attorney-General for Ireland, in 1867, in London, from whom they had obtained a promise that a clause securing proper fees for medical witnesses would be inserted in the Common Law Courts Bill. The pressure, however, of other business on Parliament, and the adjournment of the House, prevented the fulfilment of this promise. The two missions which seem destined for the College to fulfil are: 1st. To maintain its status and character as the head of the surgical profession in this country; Second. The protection and direction of that profession. Let its motto be, "Esta perpetua, el floreat semper."

awakened in all classes for personal advancement, I cannot In this time of progress, with the competition so much avoid alluding to the great additions which are being annually made to the numbers of students, but also to the numerous educational divisions of the classes which now come to this city for instruction. I recollect when there were but three of them-divinity, law, and medicine; to which there is now added the C.E., the chemical, those for civil appointments both at home and abroad, as well as those for the military and constabulary services. Of all these classes, I ask is the medical one inferior to any of them in intelligence, high aspi rations, conduct, and determination to execute their mission